Quality Improvement Resources

More than 22% of all gravid women undergo induction of labor in the United States, and the overall rate of induction of labor in the US has more than doubled since 1990 to 225 per 1,000 live births in 2006 (1). The goal of induction of labor is to achieve vaginal delivery by stimulating uterine contractions before the spontaneous onset of labor. Generally, induction of labor has merit as a therapeutic option when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure (2). The purpose of this document is to review current methods for cervical ripening and induction of labor and to summarize the effectiveness of these approaches based on appropriately conducted outcomes-based research. These practice guidelines classify the indications for and contraindications to induction of labor, describe the various agents used for cervical ripening, cite methods used to induce labor and outline the requirements for the safe clinical use of the various methods of inducing labor.

The goal of induction of labor is to achieve vaginal delivery by stimulating uterine contractions before the spontaneous onset of labor. According to the National Center for Health Statistics, the overall rate of induction of labor in the United States has increased from 90 per 1,000 births in 1989 to 184 per 1,000 live births in 1997. Generally, induction of labor has merit as a therapeutic option when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. The benefits of labor induction must be weighed against the potential maternal or fetal risks associated with this procedure. The purpose of this bulletin is to review current methods for cervical ripening and induction of labor and to summarize the effectiveness of these approaches based on appropriately conducted outcomes-based research. These practice guidelines classify the indications for and contraindications to induction of labor, describe the various agents used for cervical ripening, cite methods used to induce labor and outline the requirements for the safe clinical use of the various methods of inducing labor.

This article presents a systematic review of the research methods used to study quality improvement (QI) effectiveness in health care organizations. The review relied on existing literature as well as emergent themes to identify types of QI programs (e.g., data/feedback, information technology, staff education) and quality outcomes (e.g., mortality, morbidity, unnecessary variation). Studies were separated into four categories according to the type of organization in which the QI program was introduced: (a) hospital, (b) nursing home, (c) physician group, and (d) other health care organization. Results of the review indicate that most QI effectiveness research is conducted in hospital settings, is focused on multiple QI interventions, and utilizes process measures as outcomes. The review also yielded substantial variation with respect to the study designs used to examine QI effectiveness. The article concludes with a critique of these designs and suggestions for ways future research could address these shortcomings.

Background: Evidence-based management assumes that available research evidence is consistent with the problems and decision-making conditions faced by those who will utilize this evidence in practice. Purpose: This article attempts to identify how hospital leaders view key determinants of hospital quality and costs, as well as the fundamental ways these leaders ‘‘think’’ about solutions to quality and cost issues in their organizations. The objective of this analysis is to better inform the research agenda and approaches pursued by health services research so that this research reflects the ‘‘realities’’ of practice in hospitals. Methods: We conducted a series of semistructured interviews with a convenience sample of eight hospital and three health system leaders. Questions focused on current and future challenges facing hospitals as they relate to hospital quality, costs, and efficiency, and potential solutions to those challenges. Findings: Nine major organizational and managerial factors emerged from the interviews, including staffing, evidence-based practice, information technology, data availability and benchmarking, and leadership. Hospital leaders tend to think about these factors systemically and consider process-related factors as the important drivers of cost and quality.

OBJECTIVES: To use PERISTAT data on indicators of maternal mortality and morbidity to explore maternal health outcomes in Europe, and to discuss the implications of variations in the data sources for these indicators.
STUDY DESIGN: The PERISTAT feasibility study provides the source for this descriptive study, covering 15 European countries. Maternal mortality ratios are calculated, and data to describe maternal mortality by age, cause of death and mode of delivery are pooled for the countries that provided data.
RESULTS: Data presented show an increased risk of maternal death among older mothers and for caesarean sections compared with other modes of delivery, and the three most prevalent causes of maternal deaths reported were embolism, hypertensive diseases of pregnancy, and haemorrhage.
CONCLUSIONS: Variations in maternal mortality ratios reflect different data sources with varying levels of ascertainment in addition to differences in the number of maternal deaths. Further development is needed to construct comparable indicators of maternal morbidity.

BACKGROUND: Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed.
METHODS: We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention.
RESULTS: The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P<0.001 for the difference in changes). The intervention was also associated with reductions in the rate of postpartum hemorrhage of 500 ml or more (relative rate reduction, 45%; 95% confidence interval [CI], 9 to 71) and of 1000 ml or more (relative rate reduction, 70%; 95% CI, 16 to 78). Birth attendants' readiness to change also increased in the hospitals receiving the intervention. The effects on the use of episiotomy and prophylactic oxytocin were sustained 12 months after the end of the intervention. CONCLUSIONS: A multifaceted behavioral intervention increased the prophylactic use of oxytocin during the third stage of labor and reduced the use of episiotomy.

OBJECTIVE: The purpose of this study was to examine complications of labor induction compared to spontaneous labor in multiparas.
STUDY DESIGN: This was a retrospective cohort study of multiparous women with live, singleton pregnancies at term, who had no contraindications to labor or labor induction. Cesarean delivery was the primary outcome.
RESULTS: Of the study subjects, 7208 experienced spontaneous labor, 2190 underwent labor induction with oxytocin, and 239 underwent labor induction requiring cervical ripening agents. Oxytocin-induced multiparas were 37% more likely to require cesarean compared to those with spontaneous labor (OR, 1.37; 95% CI, 1.10-1.71) and nearly 3 times more likely to undergo cesarean when cervical ripening agents were used (OR, 2.82; 95% CI, 1.84-4.53). Women requiring cervical ripening were also 10 times more likely to spend more than 12 hours in labor than those with spontaneous labor.
CONCLUSION: Multiparas undergoing labor induction are at increased risk for obstetric complications compared to spontaneous labor.

Commentary

The increasing trend of delivering at earlier gestational ages has raised concerns of the impact on maternal and infant health. The delicate balance of the risks and benefits associated with continuing a pregnancy versus delivering early remains challenging. Among singleton live births in the United States, the proportion of preterm births increased from 9.7% to 10.7% between 1996 and 2004. The increase in singleton preterm births occurred primarily among those delivered by cesarean section, with the largest percentage increase in late preterm births. For all maternal racial/ethnic groups, singleton cesarean section rates increased for each gestational age group. Singleton cesarean section rates for non-Hispanic black women increased at a faster pace among all preterm gestational age groups compared with non-Hispanic white and Hispanic women. Further research is needed to understand the underlying reasons for the increase in cesarean section deliveries resulting in preterm birth

Objectives: Two programs targeting urban African-American women are presented as promising models for preconception care, which includes interconception care. Methods: The Grady Memorial Hospital Interpregnancy Care (IPC) Program in Atlanta, Georgia, and the Magnolia Project in Jacksonville, Florida, are described. The IPC program aims to investigate whether IPC can improve the health status, pregnancy planning and child spacing of women at risk of very low birthweight (VLBW). The Magnolia Project aims to reduce key risks in women of childbearing age, such as lack of family planning and repeat sexually transmitted diseases (STDs), through its case management activities. Results: Seven out of 21 women in the IPC were identified as having a previously unrecognized or poorly managed chronic disease. 21/21 women developed a reproductive plan for themselves, and none of the 21 women became pregnant within nine months following the birth of their VLBW baby. The Magnolia Project had a success rate of greater than 70% in resolving the key risks (lack of family planning, repeat STDs) among case management participants. The black to white infant mortality (IM) ratio was better for babies born to women managed in the Magnolia Project compared to the same ratio for the United States. Conclusions: Preconception care targeted to African-American women at risk for poor birth outcomes appears to be effective when specific risk factors are identified and interventions are appropriate. Outreach to women at risk and case management can be effective in optimizing the woman's health and subsequent reproductive health outcomes.

OBJECTIVE: To determine what factors related to health services in France might explain substandard care of severe morbidity due to obstetric haemorrhage.
DESIGN: Retrospective questionnaire survey.
SETTING: Three administrative regions of France.
POPULATION: All women who were pregnant or had recently given birth during the year before the survey.
METHODS: A European survey (MOMS-B) defined severe haemorrhages as blood loss > or = 1500mL. A specific questionnaire was added in France to analyse the quality of care of these haemorrhages. The survey was carried out in three different administrative regions: Champagne-Ardenne, the Centre and Lorraine. An expert committee was appointed and began by establishing a framework for qualitative assessment. One hundred and sixty-five cases of severe haemorrhage were reviewed and classified into one of three levels of care: appropriate, inadequate or mixed. Inadequate care and 'mixed' care were both considered substandard. The 165 cases were coded and then studied with uni- and multivariate analysis (logistic regression with SAS and SPSS software).
RESULTS: Of the 165 cases identified, 51% (85/165) were vaginal, 19% (31/165) operative vaginal, and 30% (49/165) caesarean. The leading cause of haemorrhage was uterine atony. Overall, 62% of the cases received appropriate care, 24% received totally inadequate care and 14% mixed care. After adjustment for sociodemographic factors, antenatal care and organisational aspects, the lack of a 24-hour on-site anaesthetist at the hospital and a low volume of deliveries (<500 births per year) were the factors associated with substandard care.
CONCLUSION: Organisational features are so important that application of good clinical practices for safer motherhood reinforce the need for new organisation of obstetric services. For the first time, the presence of an anaesthetist is shown to have a measurable effect on the quality of care for women giving birth. These results need to be confirmed by others.

As more quality improvement programs are implemented to achieve gains in performance, the need to evaluate their lasting effects has become increasingly evident. However, such long-term follow-up evaluations are scarce in healthcare implementation science, being largely relegated to the "need for further research" section of most project write-ups. This article explores the variety of conceptualizations of implementation sustainability, as well as behavioral and organizational factors that influence the maintenance of gains. It highlights the finer points of design considerations and draws on our own experiences with measuring sustainability, framed within the rich theoretical and empirical contributions of others. In addition, recommendations are made for designing sustainability analyses. This article is one in a Series of articles documenting implementation science frameworks and approaches developed by the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI).

OBJECTIVE: To report the distribution and availability of the indicators describing the population of childbearing women in Europe and to assess the impact of the difference in the distribution of two of these indicators (age and multiple births) on some outcome indicators.
METHODS: The six PERISTAT indicators of population characteristics were computed using data from a survey of data providers in Europe. For maternal age and multiple births, the impact on health outcome was simulated for the extremes of the distribution using indirect standardised rates.
RESULTS: Data availability is good for basic demographic indicators (age, parity, multiple births), but less complete for indicators of social characteristics (education, smoking, country of birth). Further, common definitions are not used for the latter. Simulations of the impact of maternal age on health outcome found that variation in the maternal age distribution may cause trisomy 21 rates to differ by nearly 20% and maternal mortality ratios by nearly 50%.
CONCLUSION: Indicators of basic population characteristics are not collected routinely in every country. The crude distribution of these indicators is essential for international comparisons. Interpretation of comparative data would be improved by collection of health outcomes and service use by maternal characteristics.

OBJECTIVE: To assess the ability of the member states of the European Union to produce the indicators recommended by the PERISTAT project on perinatal health indicators and to provide an overview of fetal and infant health outcomes for these countries according to the information now available.
METHODS: We used data from the PERISTAT survey of data providers to compute PERISTAT indicators of fetal and infant health.
RESULTS: National data on fetal mortality are available for all countries, but vary in their definitions. To adjust for these differences in definition, PERISTAT recommends presenting rates by gestational age and birth weight. Not all countries can provide neonatal mortality data by gestational age, birth weight or plurality, as recommended by PERISTAT. Few countries in Europe can report infant mortality rates by birth weight and gestational age. The other recommended indicators are available to varying degrees.
CONCLUSIONS: This overview, which shows that Europe can produce a variety of indicators for monitoring the health of its new-borns, indicates that some key dimensions of perinatal health cannot now be measured with routine health statistics and reveals important disparities in health outcomes throughout Europe. For most indicators, the highest values are between 50 and 100% higher than the lowest values. The reasons for these variations and their importance for the surveillance of perinatal health are discussed.

In an era of chronic resource scarcity it is critical that quality improvement professionals have confidence that their project activities cause measured change. A commonly used research design, the single group pre-test/post-test design, provides little insight into whether quality improvement interventions cause measured outcomes. A re-evaluation of a quality improvement programme designed to reduce the percentage of bilateral cardiac catheterisations for the period from January 1991 to October 1996 in three catheterisation laboratories in a north eastern state in the USA was performed using an interrupted time series design with switching replications. The accuracy and causal interpretability of the findings were considerably improved compared with the original evaluation design. Moreover, the re-evaluation provided tangible evidence in support of the suggestion that more rigorous designs can and should be more widely employed to improve the causal interpretability of quality improvement eVorts. Evaluation designs for quality improvement projects should be constructed to provide a reasonable opportunity, given available time and resources, for causal interpretation of the results. Evaluators of quality improvement initiatives may infrequently have access to randomised designs. Nonetheless, as shown here, other very rigorous research designs are available for improving causal interpretability. Unilateral methodological surrender need not be the only alternative to randomised experiments. (Quality in Health Care 2001;10:179–186)

The concept of knowing what works in terms of reducing maternal mortality is complicated by a huge diversity of country contexts and of determinants of maternal health. Here we aim to show that, despite this complexity, only a few strategic choices need to be made to reduce maternal mortality. We begin by presenting the logic that informs our strategic choices. This logic suggests that implementation of an effective intrapartum-care strategy is an overwhelming priority. We also discuss the alternative configurations of such a strategy and, using the best available evidence, prioritise one strategy based on delivery in primary-level institutions (health centres), backed up by access to referral-level facilities. We then go on to discuss strategies that complement intrapartum care. We conclude by discussing the inexplicable hesitation in decision-making after nearly 20 years of safe motherhood programming: if the fifth Millennium Development Goal is to be achieved, then what needs to be prioritised is obvious. Further delays in getting on with what works begs questions about the commitment of decision-makers to this goal.

OBJECTIVE: To estimate effective strategies for implementing clinical practice guidelines in obstetric care and to identify specific barriers to behavior change and facilitators in obstetrics.
DATA SOURCES: The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and experts' suggestions.
METHODS OF STUDY SELECTION: Studies of clinical practice guidelines implementation strategies in obstetric care and reviews of such studies were selected. Randomized controlled trials, controlled before-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organization of Care criteria standards. TABULATION, INTEGRATION,
AND RESULTS: Studies were reviewed by two investigators to assess the quality and the efficacy of each strategy. Discordances between the two reviewers were resolved by consensus. In obstetrics, educational strategies with medical providers are generally ineffective; educational strategies with paramedical providers, opinion leaders, qualitative improvement, and academic detailing have mixed effects; audit and feedback, reminders, and multifaceted strategies are generally effective. These findings differ from data on the efficacy of clinical practice guidelines implementation strategies in other medical specialties. Specific barriers to behavior change in obstetrics and methods to overcome these barriers could explain these differences. The proportion of effective strategies is significantly higher among the interventions that include a prospective identification of barriers to change compared with standardized interventions.
CONCLUSION: Prospective identification of efficient strategies and barriers to change is necessary to achieve a better adaptation of intervention and to improve clinical practice guidelines implementation. In the field of obstetric care, multifaceted strategy based on audit and feedback and facilitated by local opinion leaders is recommended to effectively change behaviors.

OBJECTIVE: To quantify adverse neonatal and maternal outcomes associated with elective term delivery at less than 39 completed weeks of gestation.
STUDY DESIGN: Prospective observational study conducted in 27 hospitals over the course of 3 months in 2007.
RESULTS: Of 17,794 deliveries, 14,955 (84%) occurred at 37 weeks or greater. Of term deliveries, 6562 (44%) were planned, rather than spontaneous. Among the planned deliveries, 4645 (71%) were purely elective; 17.8% of infants delivered electively without medical indication at 37-38 weeks and 8% of those delivered electively at 38-39 weeks required admission to a newborn special care unit for an average of 4.5 days, compared with 4.6% of infants delivered at 39 weeks or beyond (P ! .001). Cesarean delivery rate in women undergoing induction of labor was not influenced by gestational age but was highly influenced by initial cervical dilatation and parity, ranging from 0% for parous women induced at 5 cm or greater to 50% for nulliparous women at 0 cm.
CONCLUSION: Elective delivery before 39 weeks’ gestation is associated with significant neonatal morbidity. Initial cervical dilatation is highly correlated with cesarean delivery among women undergoing induction of labor in both nulliparous and parous women. Elective delivery before 39 completed weeks’ gestation is inappropriate. Women contemplating elective induction at or beyond 39 weeks’ gestation with an unfavorable cervix should be counseled regarding an increased rate of cesarean delivery.

Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes and was recently added by the institute for Safe Medication Practices to a small list of medications "bearing a heightened risk of harm," which may "require special safeguards to reduce the risk of error." Current recommendations for the administration of this drug are vague with respect to indications, timing, dosage, and monitoring of maternal and fetal effects. A review of available clinical and pharmacologic data suggests that specific, evidence-based guidelines for the intrapartum administration of oxytocin may be derived from available data. If implemented, such practices may reduce the likelihood of patient harm. These suggested guidelines focus on limited elective administration of oxytocin, consideration of strategies that have been shown to decrease the need for indicated oxytocin use, reliance on low-dose oxytocin regimens, adherence to specific semiquantitative definitions of adequate and inadequate labor, and an acceptance that once adequate uterine activity has been achieved, more time rather than more oxytocin is generally preferable. The use of conservative, specific protocols for monitoring th effects of oxytocin on mother and fetus is likely not only to improve outcomes but also reduce conflict between members of the obstetric team. Implementation of these guidelines would seem appropriate in a culture increasingly focused on patient safety.

OBJECTIVE: To explore the effect of training on patient-actor perception of care during simulated obstetric emergencies.
METHOD: A subanalysis from a prospective randomised controlled trial in six UK hospitals and the Bristol Medical Simulation Centre, UK. Midwives and doctors working in participating hospitals were eligible for inclusion. 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were randomised to one of four obstetric emergency training interventions: 1-day course at local hospitals; 1-day course at simulation centre; 2-day course with teamwork training at local hospitals; and 2-day course with teamwork training at simulation centre. Local training used patient-actors and low-fidelity part-task trainers whereas simulation centre training used full-bodied computerised manikins and high-fidelity part-task trainers. Three weeks before and after the training, the participants managed three simulated obstetric emergencies. Patient-actors scored their care after each simulation using a patient-actor perception score (communication, safety, respect).
RESULTS: The following numbers of scores were awarded: 139 and 132 participant and 46 and 48 team scenarios, before and after training, respectively. There was a significant improvement in all scores in all scenarios after the training (p = 0.017 to >0.001). Perception of safety and communication during postpartum haemorrhage was significantly improved following training with patient-actors compared with training with manikins (safety p = 0.048, communication p = 0.035). Teamwork training offered no additional benefit to patient-actors' perception of their care.
CONCLUSIONS: All multiprofessional training improved patient-actor perception of care. Training using a patient-actor may be better at improving perception of safety and communication than training with a computerised manikin simulator

OBJECTIVES: To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training.
DESIGN: A prospective randomised controlled trial.
SETTING: Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK.
POPULATION: Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied.
METHODS: Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre.
MAIN OUTCOME MEASURES: Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention.
RESULTS: There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1-23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training (P = 0.965).
CONCLUSIONS: Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.

Background: Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods: We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results: The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion: The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

In contrast with the primary goals of science, which are to discover and disseminate new knowledge, the primary goal of improvement is to change performance. Unfortunately, scholarly accounts of the methods, experiences, and results of most medical quality improvement work are not published, either in print or electronic form. In our view this failure to publish is a serious deficiency: it limits the available evidence on efficacy, prevents critical scrutiny, deprives staff of the opportunity and incentive to clarify thinking, slows dissemination of established improvements, inhibits discovery of innovations, and compromises the ethical obligation to return valuable information to the public. The reasons for this failure are many: competing service responsibilities of and lack of academic rewards for improvement staff; editors’ and peer reviewers’ unfamiliarity with improvement goals and methods; and lack of publication guidelines that are appropriate for rigorous, scholarly improvement work. We propose here a draft set of guidelines designed to help with writing, reviewing, editing, interpreting, and using such reports. We envisage this draft as the starting point for collaborative development of more definitive guidelines. We suggest that medical quality improvement will not reach its full potential unless accurate and transparent reports of improvement work are published frequently and widely.

In 2005, draft guidelines were published for reporting studies of quality improvement interventions as the initial step in a consensus process for development of a more definitive version. This article contains the full revised version of the guidelines, which the authors refer to as SQUIRE (Standards for QUality Improvement Reporting Excellence). This paper also describes the consensus process, which included informal feedback from authors, editors and peer reviewers who used the guidelines; formal written commentaries; input from a group of publication guideline developers; ongoing review of the literature on the epistemology of improvement and methods for evaluating complex social programmes; a two-day meeting of stakeholders for critical discussion and debate of the guidelines’ content and wording; and commentary on sequential versions of the guidelines from an expert consultant group. Finally, the authors consider the major differences between SQUIRE and the initial draft guidelines; limitations of and unresolved questions about SQUIRE; ancillary supporting documents and alternative versions that are under development; and plans for dissemination, testing and further development of SQUIRE.

Background: Comparing the relative effectiveness of interventions on specific outcomes across trials can be problematic due to differences in the choice and definitions of outcome measures used by researchers. We sought to identify a minimum set of outcome measures for evaluating models of maternity care from the perspective of key stakeholders. Methods: A 3-round, electronic Delphi survey design was used. Setting was multinational, comprising a range of key stakeholders. Participants consisted of a single heterogeneous panel of maternity service users, midwives, obstetricians, pediatricians/neonatologists, family physicians/general practitioners, policymakers, service practitioners, and researchers of maternity care. Members of the panel self-assessed their expertise in evaluating models of maternity care. Results: A total of 320 people from 28 countries expressed willingness to take part in this survey. Round 1 was completed by 218 (68.1%) participants, of whom 173 (79.4%) completed round 2 and 152 (87.9%) of these completed round 3. Fifty outcomes were identified, with both a mean value greater than the overall group mean for all outcomes combined (x= 4.18) and rated 4 or more on a 5-point Likert-type scale for importance of inclusion in a minimum data set of outcome measures by at least 70 percent of respondents. Three outcomes were collapsed into a single outcome so that the final minimum set includes 48 outcomes. Conclusions: Given the inconsistencies in the choice of outcome measures routinely collected and reported in randomized evaluations of maternity care, it is hoped that use of the data set will increase the potential for national and international comparisons of models for maternity care. Although not intended to be prescriptive or to inhibit the collection of other outcomes, we hope that the core set will make it easier to assess the care of women and their babies during pregnancy and childbirth. (BIRTH 34:2 June 2007)

OBJECTIVES: To determine whether the introduction of Obstetrics Emergency Training in line with the recommendations of the Clinical Negligence Scheme for Trusts (CNST) was associated with a reduction in perinatal asphyxia and neonatal hypoxic-ischaemic encephalopathy (HIE).
DESIGN: A retrospective cohort observational study.
SETTING: A tertiary referral maternity unit in a teaching hospital.
POPULATION: Term, cephalic presenting, singleton infants born at Southmead Hospital between 1998 and 2003 were identified; those born by elective Caesarean sections were excluded.
METHOD: Five-minute Apgar scores were reviewed. Infants that developed HIE were prospectively identified throughout this period. The study compared the period 'pre-training' (1998-1999), with the period 'post-training' (2001-2003).
MAIN OUTCOME MEASURES: Five-minute Apgar scores and HIE.
RESULTS: Infants (19,460) were included. Infants born with 5-minute Apgar scores of <or=6 decreased from 86.6 to 44.6 per 10,000 births (P<0.001) and those with HIE decreased from 27.3 to 13.6 per 10,000 births (P=0.032) following the introduction of the training courses in 2000. Antepartum and intrapartum stillbirth at term rates remained unchanged, at about 15 and 4 per 10,000 births, respectively.
CONCLUSION: The introduction of obstetric emergencies training courses was associated with a significant reduction in low 5-minute Apgar scores and HIE. This improvement has been sustained as the training has continued. This is the first time an educational intervention has been shown to be associated with a clinically important, and sustained, improvement in perinatal outcome.

Background: In quality improvement collaboratives (QICs) teams of practitioners from different health care organizations are brought together to systematically improve an aspect of patient care. Teams take part in a series of meetings to learn about relevant best practices, quality methods and change ideas, and share experiences in making changes in their own local setting. The purpose of this study was to develop an instrument for measuring team organization, external change agent support and support from the team's home institution in a Dutch national improvement and dissemination programme for hospitals based on several QICs. Methods: The exploratory methodological design included two phases: a) content development and assessment, resulting in an instrument with 15 items, and b) field testing (N = 165). Internal consistency reliability was tested via Cronbach's alpha coefficient. Principal component analyses were used to identify underlying constructs. Tests of scaling assumptions according to the multi trait/multi-item matrix, were used to confirm the component structure. Results: Three components were revealed, explaining 65% of the variability. The components were labelled 'organizational support', 'team organization' and 'external change agent support'. One item not meeting item-scale criteria was removed. This resulted in a 14 item instrument. Scale reliability ranged from 0.77 to 0.91. Internal item consistency and divergent validity were satisfactory. Conclusion: On the whole, the instrument appears to be a promising tool for assessing team organization and internal and external support during QIC implementation. The psychometric properties were good and warrant application of the instrument for the evaluation of the national programme and similar improvement programmes.

Introduction: Despite the popularity of quality improvement collaboratives (QICs) in different healthcare settings, relatively little is known about the implementation process. The objective of the current study is to learn more about relations between relevant conditions for successful implementation of QICs, applied changes, perceived successes, and actual outcomes. Methods: Twenty-four Dutch hospitals participated in a dissemination programme based on QICs. A questionnaire was sent to 237 leaders of teams who joined 18 different QICs to measure changes in working methods and activities, overall perceived success, team organisation, and supportive conditions. Actual outcomes were extracted from a database with team performance indicator data. Multi-level analyses were conducted to test a number of hypothesised relations within the cross-classified hierarchical structure in which teams are nested within QICs and hospitals. Results: Organisational and external change agent support is related positively to the number of changed working methods and activities that, if increased, lead to higher perceived success and indicator outcomes scores. Direct and indirect positive relations between conditions and perceived success could be confirmed. Relations between conditions and actual outcomes are weak. Multi-level analyses reveal significant differences in organisational support between hospitals. The relation between perceived successes and actual outcomes is present at QIC level but not at team level. Discussion: Several of the expected relations between conditions, applied changes and outcomes, and perceived successes could be verified. However, because QICs vary in topic, approach, complexity, and promised advantages, further research is required: first, to understand why some QIC innovations fit better within the context of the units where they are implemented; second, to assess the influence of perceived success and actual outcomes on the further dissemination of projects over new patient groups.

Induction of labor has become routine practice in perinatal units across the United States, with rates reaching a high of 21.2% of births in 2003-2004. This article describes the process our institution used to standardize the criteria for scheduling inductions. Specifically, we aimed to increase the consistency in practice for scheduling and performing elective inductions, including mandating gestational age of 39 completed weeks, ensuring cervical ripeness, and disallowing the use of cervical ripening agents. The nurses’ participation, from planning to implementation, was critical in the success of this evidence-based practice change.

OBJECTIVE: To compare the effectiveness of training for eclampsia in local hospitals and a regional simulation center, with and without teamwork theory.
METHODS: This study is a randomized controlled trial of training in local hospitals and in a simulation center in the United Kingdom. Midwives and obstetricians working at participating hospitals were randomly assigned to 24 teams. Teams were randomly allocated to training in local hospitals or at a simulation center, and to teamwork theory or not. Performance was evaluated before and after training with a standardized eclampsia scenario captured on video. Outcome measures were completion of tasks, time to completion of tasks, administration of magnesium sulfate, and quality of teamwork.
RESULTS: Training was associated with an increase in completion of basic tasks; 87% before training and 100% afterward. Basic tasks were completed more quickly; 55 seconds compared with 27 seconds, P=.012. The magnesium sulfate loading dose was administered by 61% of teams before training and by 92% afterward (P=.040). There was a shorter median time to administration (116 seconds less; P=.011). Training at the simulation center was not associated with additional improvement. Teamwork generally improved (median global score rose from 2.5 to 4.0; P<.001) but there was no additional benefit from teamwork training.
CONCLUSION: Training resulted in enhanced performance with higher rates of completion for basic tasks, shorter times to administration of magnesium sulfate, and improved teamwork. There was no additional benefit from training in a simulation center, and none from teamwork theory.
CLINICAL TRIAL REGISTRATION: ISRCTN, http://isrctn.org, ISRCTN67906788, reference number 0270030.

OBJECTIVE: To examine the effects that medical staff education and a new process for scheduling inductions had on decreasing inappropriate inductions.
METHODS: At our institution in 2004, guidelines were developed and shared with the medical staff and reinforced in 2005. The guidelines for elective induction required patients to have completed 39 weeks of gestation and to have a Bishop score of at least 8 for nulliparas and 6 for multiparas. In 2006, the induction scheduling process was changed and the guidelines were strictly enforced. All scheduled inductions during the same 3-month time period (June through August) in 2004 (n=533) and 2005 (n=454) and during a 13-month period from November 2006 to December 2007 (n=1,806) were compared. Outcomes included elective inductions less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and the overall induction rate.
RESULTS: From 2004-2007, the overall induction rate dropped from 24.9% to 16.6%, a 33% reduction(P<.001); the elective induction rate dropped from 9.1% to 6.4%, a 30% reduction (P<.001); the percentage of elective inductions before 39 weeks of gestation dropped from 11.8% to 4.3%, a decrease of 64% (P<.001); and the frequency of cesarean delivery among nulliparas undergoing elective induction dropped from 34.5% to 13.8%, a decrease of 60%. (P=.01).
CONCLUSION: Medical staff education and the development and enforcement of induction guidelines contributed to a decrease in inappropriate inductions, a lower cesarean birth rate for electively induced nulliparas, and a lower elective and overall induction rate.

BACKGROUND: Previous reviews have shown inconsistent effects of publicly reported performance data on quality of care, but many new studies have become available in the 7 years since the last systematic review.
PURPOSE: To synthesize the evidence for using publicly reported performance data to improve quality.
DATA SOURCES: Web of Science, MEDLINE, EconLit, and Wilson Business Periodicals (1999-2006) and independent review of articles (1986-1999) identified in a previous systematic review. Only sources published in English were included.
STUDY SELECTION: Peer-reviewed articles assessing the effects of public release of performance data on selection of providers, quality improvement activity, clinical outcomes (effectiveness, patient safety, and patient-centeredness), and unintended consequences.
DATA EXTRACTION: Data on study participants, reporting system or level, study design, selection of providers, quality improvement activity, outcomes, and unintended consequences were extracted.
DATA SYNTHESIS: Forty-five articles published since 1986 (27 of which were published since 1999) evaluated the impact of public reporting on quality. Many focus on a select few reporting systems. Synthesis of data from 8 health plan-level studies suggests modest association between public reporting and plan selection. Synthesis of 11 studies, all hospital-level, suggests stimulation of quality improvement activity. Review of 9 hospital-level and 7 individual provider-level studies shows inconsistent association between public reporting and selection of hospitals and individual providers. Synthesis of 11 studies, primarily hospital-level, indicates inconsistent association between public reporting and improved effectiveness. Evidence on the impact of public reporting on patient safety and patient-centeredness is scant.
LIMITATIONS: Heterogeneity made comparisons across studies challenging. Only peer-reviewed, English-language articles were included.
CONCLUSION: Evidence is scant, particularly about individual providers and practices. Rigorous evaluation of many major public reporting systems is lacking. Evidence suggests that publicly releasing performance data stimulates quality improvement activity at the hospital level. The effect of public reporting on effectiveness, safety, and patient-centeredness remains uncertain.

A great essay on the history of the APGAR score and how obstetrics has changed with its focus on baby outcomes over the last generation. Atul Gawande's writing style works well for both lay and professional audiences.

This is an essay on the use of checklists in medical quality improvement and profiles Peter Pronovost's translational research in their use in ICUs. Atul Gawande's writing style works wonderfully for both lay and professional audiences. This is a great tool to use when introducing a checklist into a new medical service.

Rationale: There is a pressing need for practical clinical trials (PCTs) that are more relevant to clinicians and decision-makers, but many are unaware of these trials. Furthermore, such trials can be challenging to conduct and to report. Objective: The objective of this study was to build on the seminal paper by Tunis et al (Practical clinical trials. Increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003;290:1624 –1632.) and to provide recommendations and examples of how practical clinical trials can be conducted and the results reported to enhance external validity without sacrificing internal validity. Key Issues: We discuss evaluating practical intervention options, alternative research designs, representativeness of samples participating at both the patient and the setting/clinician level, and the need for multiple outcomes to address clinical and policy implications. Conclusions: We provide a set of specific recommendations for issues to be reported in PCTs to increase their relevance to clinicians and policymakers, and to help reduce the gap between research and practice.

Commentary

OBJECTIVES: To estimate women’s understanding of the definition of full term and the gestational age at which it is safe to deliver an otherwise healthy pregnancy. METHODS: A national sample of 650 insured women who recently gave birth were surveyed about their beliefs related to the meaning of full term and the safety of delivery at various gestational ages. Descriptive statistics including means and 95% confidence intervals were calculated for the demographic variables and survey measures; multivariate logistic regression analyses were also performed. RESULTS: Twenty-four percent of women surveyed considered a baby of 34–36 weeks of gestation to be full term, and 50.8% believed full term to occur at 37–38 weeks of gestation, while only 25.2% considered full term to occur at 39–40 weeks of gestation. In response to,“What is the earliest point in pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?” 51.7% choose 34–36 weeks of gestation, and 40.7% choose 37–38 weeks of gestation, while only 7.6% choose 39–40 weeks of gestation. CONCLUSION: The American College of Obstetricians and Gynecologists recommends that elective deliveries not occur before 39 weeks of gestation. However, many women believe that full term is reached before 37 weeks of gestation, and most believe full term occurs before 39 weeks of gestation. Nearly half believe it is safe to deliver before 37 weeks of gestation, and almost all believe it is safe to deliver before 39 weeks of gestation. The data reported here suggest that many women believe that term is reached early and that a safe delivery does not require waiting to 39 weeks of gestation.

BACKGROUND: Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline.
METHODS: This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals.
RESULTS: Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use.
CONCLUSIONS: When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

The need to monitor progress in reducing maternal mortality has a long history, which can be traced back to the 1700s in some parts of the Western world. Today, however, this need is felt most acutely in developing countries, where the priority is to stimulate, evaluate and sustain action to prevent these essentially avoidable deaths. Over the last two decades, considerable efforts have been made to understand and overcome the measurement challenges of maternal mortality in the context of weak information systems, and new and enhanced methods and tools have emerged.

This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.

Objectives: To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines. Data sources: MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group. Review methods: Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care. Results: In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources. Conclusions: There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

This article outlines an approach to improve patient safety in obstetrics and gynecology, with the goal to reduce errors in labor and delivery. Every institution should create guidelines and provide education and training to address potential safety issues such as fetal heart rate pattern interpretation, induction and stimulation of labor, vaginal birth after cesarean, magnesium sulfate, shoulder dystocia, hemorrhage, forceps/vacuum, and thromboembolic disease. This article discusses the patient safety objectives published by the American College of Obstetricians and Gynecologists Committee on Quality Improvement and Patient Safety; the National Patient Safety Goals, which are regularly established by the Joint Committee on Accreditation of Healthcare Organizations; and patient safety indicators developed by the Agency for Healthcare Research and Quality.

Oxytocin is 1 of the most commonly used drugs in labor and has been associated with adverse maternal and fetal outcomes. In an attempt to improve patient safety, we constructed a standardized protocol for labor induction with oxytocin. We reviewed the numerous publications regarding oxytocin use for either induction or augmentation of labor in order to determine if there was a protocol available that would maximize success of delivery and minimize the adverse maternal and fetal effects of the drug. Using the literature review and the specific pharmacokinetics of oxytocin, we developed a standardized approach for the dilution and administration of oxytocin in order to improve patient safety, develop uniformity of the drug use, maximize its benefits, and minimize its side effects. We suggest that a standardized approach to oxytocin use be adopted that uses an oxytocin dilution of 10 mU/mL, initial dose of 2 mU/min (12 mL/hr), incremental increase of 2 mU (12 mL) every 45 minutes until adequate labor with the maximum dose being 16 mU/min (96 mL/hr). Key words: augmentation, induction, oxytocin, Pitocin

Issues related to the development and implementation of clinical pathways require thoughtful planning, collaborative teamwork, and an understanding of the evolutionary nature of this work. Creating an understanding of the purpose behind the development of these guidelines often is only the first issue to be considered. Other common issues include physician involvement, documentation, pathway development, variance data analysis and feedback, and integration with outcomes management activities. Successfully addressing these issues is an ongoing component of a clinical pathway program.

One of the biggest challenges a newborn faces after birth is the task of making a smooth transition to air breathing. This task is complicated by the fact that fetal lungs are full of fluid which must be cleared rapidly to allow for gas exchange. Respiratory morbidity as a result of failure to clear fetal lung fluid is not uncommon, and can be particularly problematic in some infants delivered by elective cesarean delivery (ECS). Given the high rates of cesarean deliveries in the USA and worldwide, the public health and economic impact of morbidity in this subgroup is considerable. Whereas the occurrence of birth asphyxia, trauma, and meconium aspiration is reduced by elective Cesarean delivery, the risk of respiratory distress secondary to transient tachypnea of the newborn,surfactant deficiency, and pulmonary hypertension is increased. It is clear that physiologic events in the last few weeks of pregnancy coupled with the onset of spontaneous labor are accompanied by changes in the hormonal milieu of the fetus and its mother, resulting in preparation of the fetus for neonatal transition. Rapid clearance of fetal lung fluid is a key part of these changes, and is mediated in large part by transepithelial Na reabsorption through amiloride-sensitive Na channels in the alveolar epithelial cells, with only a limited contribution from mechanical factors and Starling forces. This chapter discusses the physiologic mechanisms underlying fetal lung fluid absorption and explores potential strategies for facilitating neonatal transition when infants are delivered by ECS before the onset of spontaneous labor.

Background: Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective. Objectives: To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. Search strategy: We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004. Selection criteria: Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Data collection and analysis: Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality. Main results: Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies. Authors' conclusions: Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.

This article describes the design, implementation, and evaluation of an interdisciplinary clinical pathway system for maternal newborn care in a perinatal regional referral institution. Core issues in the design of this system are addressed to promote outcomes management and ongoing performance improvement. A discussion of the implementation follows, illustrating the lessons learned, changes made, and associated evaluation. This clinical pathway system has improved communication and collaboration among all disciplines, enhanced the discharge coordination process, and established protocols available to all members of the health care team.

ABSTRACT Objective: To explore the practice of midwifery within a busy urban tertiary hospital birth setting and to present findings on the relationships between nurses and midwives in providing maternity care. Design/Method: A focused ethnography on midwifery practice conducted over 2 years (2004-2006) in a teaching hospital serving a primarily Medicaid-eligible population in Northern California. Data were collected through participant observations and in-depth interviews with midwives (N511) and nurses (N514). Practices and relationships among the midwives and nurses were examined in an ethnographic framework through thematic analysis. Findings: Two themes described the nature of nursing-midwifery relationships: tension and teamwork. Tension existed in philosophic approaches to care, definitions of safe practice, communication, and respect. Teamwork existed when the midwives and nurses worked in partnership with the woman to develop a plan of care. Changes were brought about to improve the midwife-nurse relationship during the conduct of the study. Conclusions: Midwives and nurses experienced day-to-day challenges in providing optimal care for childbearing women. The power of effective teamwork was profound, as was the tension when communication broke down. Failure to include nurses resulted in impaired translation of evidence into practice. All stakeholders in birth practices and policy development must be involved in future research in order to develop effective maternity care models.

Australia is one of the safest countries in the world to birth. Because maternal deaths are rare, often the focus during pregnancy is on the well-being of the fetus. The relative safety of birth has fostered a shift in the focus of maternal health, from survival, to the model of care or the birth experience. Yet women still die in Australia as a result of child bearing and many of these deaths are associated with avoidable factors. The purpose of this paper is to outline the maternal death monitoring and review process in Australia and to present to clinicians the salient features of the most recently published Australian maternal death report. The notion of preventability and the potential for practice to have an effect on reducing maternal mortality are also discussed.

Clinical pathways have been implemented in many healthcare settings as a link between evidence and practice. Most published research concludes that when clinical pathways are implemented and used by health professionals, there is a positive impact on health outcomes. However, some research also suggests that utilization of clinical pathways by health professionals is low and that implementation strategies for linking evidence with clinical practice often prove to be weak or ineffective. This paper describes a before and after study to determine whether an interdisciplinary, genuinely collaborative, and evidence-based process of clinical pathway implementation resulted in increased documented use of an acute myocardial infarction (AMI) clinical pathway by health professionals in a regional Australian hospital. Underpinning the design and implementation process was the belief that true team involvement would lead to ownership, acceptance, and, ultimately, to increased usage of the pathway. Documented clinical pathway usage was measured in two ways: (1) the presence of the AMI clinical pathway in the medical records of patients diagnosed with an AMI and (2) the proportion of the AMI clinical pathway completed when it was present in the medical record. A total of 195 medical records of those diagnosed with an AMI were audited before (n = 124) and after (n = 71) the implementation process. The interdisciplinary, truly collaborative, and evidence-based implementation process resulted in a statistically significant increase in documented usage of the AMI pathway (22.6% vs. 57.7%; p <.000). Results indicate that involvement of key users in the design and implementation of a clinical pathway significantly increases staff utilization of the document.

Clinical pathways have been designed to provide an effective interface between evidence and practice in healthcare. Strong evidence supports the assertion that when clinical pathways are utilized they improve outcomes. However, published evidence measuring the uptake of clinical pathways by health professionals remains sparse. This article presents a study evaluating the degree of documented compliance with the clinical pathway chart used for patients diagnosed with an acute myocardial infarction (AMI) in a major Australian regional hospital. The relationships between compliance and demographic and illness were also examined. Data were collected from 124 records with the result that the level of documented compliance was 16.5%. Clients with private health insurance had significantly higher documented compliance with the clinical pathway than those with no private health insurance. There were also significant variations in documented compliance according to the type of AMI recorded. Recommendations to improve compliance with clinical pathways are included along with recommendations for future research.

As 200 million women become pregnant every year, at least 30 million will develop life-threatening complications requiring emergency treatment at any level of society where they live. But it is a basic human right that pregnancy be made safe for all women as complications are mostly unpredictable. This requires reproductive health programmes which are responsive to women's and their families' needs and expectations on the one hand and enhancement of community participation, high quality obstetric services, and both provider collaboration and satisfaction on the other. Monitoring and evaluation of these facets need to be an integral part of any safe motherhood programme, not only to assess progress, but also to use this information for subsequent planning and implementation cycles of national programmes. Lessons learned from ten years' implementation of Safe Motherhood programmes indicate that process and outcome indicators are more feasible for short-term evaluation purposes than impact indicators, such as maternal mortality reduction. The former are described in this paper with relevant country examples. This is the third, and last, article in a series on quality of care in reproductive health programmes. The first (Kwast 1998a) contains an overview of concepts, assessments, barriers and improvements of quality of care. The second (Kwast 1998b) addresses education issues for quality improvement. PIP: This article outlines the quality of care in reproductive health programs by monitoring and evaluating quality improvements. Values of medical audit, verbal autopsies, and selected process and outcome indicators pertaining to safe motherhood component of reproductive health programs are illustrated to measure various aspects of quality of care. The International Federation of Gynecology and Obstetrics (FIGO) recommends the method of maternal death audits for the purpose of teaching and improving services at all level in the maternity care pyramid. In the selection process and outcome indicators, this requires collaboration between various international agencies and universities. Each projects and programs should require appropriate indicators for monitoring and evaluation; hence, the choice will depend on program interventions. The availability of humane and functioning obstetric services, which are geographically accessible and financially affordable, encourages families to seek care. Moreover, discussions in improving quality must consider client satisfaction and provider fulfillment.

The main purpose of this article is to point out common pitfalls that can confuse comparative analyses of indicators of perinatal health and to discuss ways to overcome or minimize these difficulties. The challenge is to distinguish 'real' variations in the value of an indicator from variations due to differences in registration practices and definitions and from random variation. The first section presents the major properties that are desirable in indicators of perinatal health status and perinatal health care in Europe to be used for comparative purposes. The second section provides specific examples of the types of methodological difficulties encountered in European cross-country comparisons due to variations in the definition, measurement and construction of indicators. The conclusion discusses the PERISTAT project's responses to these difficulties and how these methodological constraints impact on the selection of an appropriate indicator set for Europe today.

Five years ago, the Institute of Medicine (IOM) called for a national effort to make health care safe. Although progress since then has been slow, the IOM report truly “changed the conversation” to a focus on changing systems, stimulated a broad array of stakeholders to engage in patient safety, and motivated hospitals to adopt new safe practices. The pace of change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury. If directed toward hospitals that actually achieve high levels of safety, pay for performance could provide additional incentives. But improvement of the magnitude envisioned by the IOM requires a national commitment to strict, ambitious, quantitative, and well-tracked national goals. The Agency for Healthcare Research and Quality should bring together all stakeholders, including payers, to agree on a set of explicit and ambitious goals for patient safety to be reached by 2010.

OBJECTIVE: To analyze the influence of level of perinatal care of the maternity unit on the rate of cesarean delivery during labor among women with low-risk pregnancies.
METHODS: Using data from the PREMODA (PREsentation et MODe d'Accouchement: presentation and mode of delivery) study of 138 French maternity units, the delivery method in 3,654 low-risk nulliparas (live singleton fetus in cephalic presentation at term [37-41 weeks of gestation], born weighing 2,500-4,500 g, no uterine scar, no cesarean before labor, and no induction of labor for maternal or fetal disorders) was analyzed. Independent variables included maternal and fetal characteristics and the level of perinatal care of the maternity unit (level 1, 2a, 2b, and 3; where levels 2b and 3 routinely manage high-risk pregnancies). Univariable and multivariable analysis with a multilevel logistic model explored the factors associated with cesarean delivery during labor.
RESULTS: Overall, the rate of cesarean during labor was 11.7%. The rate was significantly higher in level 2b (odds ratio 1.5, 95% confidence interval 1.1-2.1) and 3 (odds ratio 1.3, 95% confidence interval 1.0-1.9) maternity units than in level 1 facilities. The size and status of the facilities did not significantly affect these rates. Risk factors for cesarean were older maternal age, non-French origin, gestational age of 41 weeks, male sex, and high birth weight.
CONCLUSION: Maternity units that frequently manage high-risk pregnancies (levels 2b and 3) have higher rates of cesareans during labor for their population of nulliparas at low risk than do facilities that deal mainly with low-risk pregnancies (level 1).
LEVEL OF EVIDENCE: II-2.

Every year, some eight million women around the world suffer pregnancy-related complications; over half a million of these women die. Although most of these deaths could be averted at little or no extra cost, even where resources are limited, if we are to take action and develop and implement changes to maternity services to save the lives of mothers and newborns, we need the right kind of information. This more in-depth information might not be available through national statistics on maternal mortality rates or death certificate data; what is required is a detailed understanding of the clinical, social, cultural and other underlying factors that result in a mother's death. The World Health Organization's programme and philosophy for such maternal death or disability reviews is called Beyond the numbers. It outlines the five key methodologies for reviewing maternal deaths or disabilities that are now being introduced in a number of countries around the world.

OBJECTIVE: To identify processes affecting agency for safety among perinatal nurses, physicians, and certified nurse-midwives.
DESIGN: Grounded theory, as informed by Strauss and Schatzman.
SETTING: Two academic perinatal units in the western United States.
PARTICIPANTS: Purposive sample of 12 registered nurses, 5 physicians, and 2 certified nurse-midwives.
FINDINGS: Agency for safety (the willingness to take a stand on an issue of concern) fluctuated for all types of providers depending on situational context and was strongly influenced by interpersonal relationships. While physicians and certified nurse-midwives believed that they valued nurses' contributions to care, their units had deeply embedded hierarchies. Nurses were structurally excluded from important sources of information exchange and from contributing to the plan of care. Nurses' confidence was a key driver for asserting their concerns. Confidence was undermined in novel or ambiguous situations and by poor interpersonal relationships, resulting in a process of redefining the situation as a problem of self.
CONCLUSIONS: Women and babies should not be dependent on the interpersonal relationships of providers for their safety. Clinicians should be aware of the complex social pressures that can affect clinical decision making. Continued research is needed to fully articulate facilitators and barriers to perinatal safety.

This paper uses the results of the PERISTAT feasibility study to assess the extent to which the participating countries of Europe were able to provide data to construct the core and recommended indicators of perinatal health defined in the project. After describing the approaches used for data collection in participating countries, this paper describes the extent to which they were able to provide the data requested to construct the indicators. It documents data sources within each country and their characteristics. The paper then discusses influences on the agenda, particularly the extent to which data collection occurs as a by-product of other processes such as civil registration and the administration of health care and how these processes can both enable and impede data collection. It closes by suggesting how data collection in Europe can be improved in order to widen the scope of the agenda for compiling perinatal indicators.

Babies of 37–41 wk gestation are, by international convention, said to be born at ‘term’, but some still develop respiratory distress. It is not clear how mature a baby has to be to be free of risk of primary surfactant deficiency. An area-based retrospective study of all the 179 701 babies of 34 or more weeks’ gestation born alive in a defined area of the north of England in 1988–92 identified 149 babies with features of respiratory distress typical of surfactant deficiency severe enough to be managed with ventilatory support and with no evidence of aspiration or intrapartum infection. Gestation was carefully cross-validated against antenatal information, including at least one ultrasound assessment in the first half of pregnancy. Thirty-six of these babies were born at or after 37 wk gestation. Only 4 of the 35 delivered at 37–38 wk went into spontaneous labour. Seven became ill enough to be candidates for ECMO and two died. A review of all neonatal deaths in the study area between 1981 and 1995 identified four similar deaths in 1981–87 and two in 1993– 95. Babies who are not premature, using the internationally agreed definition, can show signs of potentially lethal pulmonary immaturity at birth, especially if subjected to pre-labour Caesarean delivery. Those born at 37–38 wk are 120 times more likely to receive ventilatory support for surfactant deficiency than those born at 39–41 wk. Elective delivery should only be undertaken before 39 wk gestation for good medical reasons. & Assisted ventilation, epidemiology, mortality, population study, surfactant deficiency, term infant

OBJECTIVE: The purpose of this study was to identify an appropriate population and a balanced set of maternal and neonatal measures to drive a hospital network obstetric quality improvement program.
STUDY DESIGN: Sutter Health, a large Northern California health care system with>40,000 births annually, served as the site for this project. We chose to focus on the standardized nulliparous patients: term, singleton, and vertex. A multidisciplinary task force evaluated and selected perinatal outcome and process measures. Data from every hospital were collected prospectively electronically and analyzed centrally.
RESULTS: Outcome measures that were selected included term, singleton, and vertex rates of 3rd/4th-degree laceration, cesarean birth, 5-minute Apgar score of <7, and patient satisfaction. The process measures included episiotomy, induction (37-41 weeks), and admittance with cervical dilation of > or =3 cm. Data collection completeness improved each quarter; by the end of 2002, the data collection completeness rate had reached 99.7%. Every measure demonstrated a large variation among our hospitals, which indicates opportunities for improvement.
CONCLUSION: This balanced set of measures for term, singleton, and vertex patients has been straightforward to collect over a large and diverse hospital system and has engaged all participants successfully.

Background: The multi-organizational collaborative is a popular model for quality improvement (QI) initiatives. It assumes organizations will share information and social support. However, there is no comprehensive documentation of the extent to which teams do interact. Considering QI collaboratives as networks, interactions among teams were documented, and the associations between network roles and performance were examined. Methods: A telephone survey of official team contact persons for 94 site teams in three QI collaboratives was conducted in 2002 and 2003. Four performance measures were used to assess the usefulness of ties to other teams and being considered a leader by peers. Results: Eighty percent of the teams said they would contact another team again if they felt the need. Teams made a change as a direct result of interaction in 86% of reported relationships. Teams typically exchanged tools such as software and interacted outside of planned activities. Having a large number of ties to other teams is strongly related to the number of mentions as a leader. Both of these variables are related to faculty-assessed performance, number of changes the team made to improve care, and depth of those changes. Discussion: The findings suggest that collaborative teams do indeed exchange important information, and the social dynamics of the collaboratives contribute to individual and collaborative success.

Martin JA. United States vital statistics and the measurement of gestational age. Paediatric and Perinatal Epidemiology 2007; 21(Suppl. 2): 13–21. Estimates of the gestational age of the newborn based on US Birth Certificate data are extensively used to monitor trends in infant and maternal health and to improve our understanding of adverse pregnancy outcome. Two measures of gestational age, the ‘date of the last normal menses’ (LMP) and the ‘clinical estimate of gestation’ (CE), have been available from birth certificate data since 1989. Reporting irregularities with the LMP-based measure are well-documented, and important questions remain regarding the derivation of the CE. Changes in perinatal medicine and in vital statistics reporting in recent years may have importantly altered gestational age data based on vital statistics. This study describes how gestational age measures are collected and edited in US national vital statistics, and examines changes in the reporting of these measures by race and Hispanic origin between 1990 and 2002. Data are drawn from the National Center for Health Statistics’ restricted use US birth files for 1990–2002. Bivariable statistics are used. The percentage of records with missing LMP dates declined markedly over the study period, overall, and for each racial/Hispanic origin group studied. A marked shift in the distribution of the CE of gestational age was also observed, suggesting changes both in the true distribution of age at birth, and in the derivation of this measure. Agreement between the LMP-based and CE estimates increased over the study period, especially among preterm births. However, a high proportion of LMP dates continue to be missing or invalid and the derivation of the CE is still uncertain. In sum, although the reporting of gestational age measures in vital statistics appears to have improved between 1990 and 2002, substantial concerns with both the LMP-based and the CE persist. Efforts to identify approaches to further improve upon the quality of these data are needed.

Objective: To determine the effects of elective induction on the risk of cesarean delivery in a cohort of women with low-risk term pregnancies and to evaluate the costs of elective induction services within our hospital system. Methods: Records of 1135 eligible women with low-risk, singleton, vertex pregnancies at 38 – 41 weeks’ gestation who were eligible for vaginal delivery were analyzed retrospectively after elective induction (n 􏰆􏰆􏰆 263) or spontaneous labor (n 􏰆􏰆􏰆 872). Outcome measures included cesarean delivery and direct costs. Variables evaluated were parity, maternal age, estimated gestational age, birth weight, prior cesarean delivery, epidural anesthetic use, and provider category. Analysis was by univariable and multivariable regression modeling. Results: Elective induction placed nulliparas at a twofold higher risk for cesarean delivery (odds ratio 2.4, 95% confidence interval 1.2, 4.9) after adjustment for birth weight, maternal age, and gestational age. We found a significantly increased risk of cesarean delivery with increased birth weight for nulliparas (2– 66.7%). Increasing maternal age increased the risk of cesarean delivery in all parity groups (P <<< .05), but particularly among nulliparas (3–26.3%) (P <<< .001). Electively induced labors that ended in vaginal delivery cost $273 more and required an average of 4 hours more in the hospital before delivery than did noninduced vaginal deliveries (P <<< .001). Conclusion: Elective induction significantly increased the risk of cesarean delivery for nulliparas, and increased in-hospital predelivery time and costs. (Obstet Gynecol 2000; 95:917–22. © 2000 by The American College of Obstetri- cians and Gynecologists.)

PURPOSE: To describe the application of the Quality of Health Outcomes Model, introduced by the American Academy of Nursing Expert Panel on Quality of Health Care, to obstetrical care, particularly second-stage labor.
ORGANIZING FRAMEWORK: The model is different from the more linear structure-process-outcome frameworks used in the past to a dynamic conceptualization of reciprocal relationships among the system, intervention, client, and outcome components. Analysis of these components can provide a comprehensive picture of the complexity of patient care decision making in hospital labor and delivery units.
CONCLUSIONS: Research findings indicate that interventions such as cesarean delivery and epidural analgesia may result in several significant quality of health outcomes for women that should receive increased attention. Uses of this model for shaping best practices among physicians and nurses and for setting directions for priorities in future interdisciplinary research and health policy are discussed.

Proposals that medical malpractice claims be removed from the tort system and processed in an alternative system, known as administrative compensation or "health courts," attract considerable policy interest during malpractice "crises," including the current one. This article describes current proposals for the design of a health court system and the system's advantages for improving patient safety. Among these advantages are the cultivation of a culture of transparency regarding medical errors and the creation of mechanisms to gather and analyze data on medical injuries. The article discusses the experiences of foreign countries with administrative compensation systems for medical injury, including their use of claims data for research on patient safety; choices regarding the compensation system's relationship to physician disciplinary processes; and the proposed system's possible limitations.

Background: Practitioners and policymakers need credible evidence of effectiveness to justify allocating resources to complex, expensive health programs. Investigators, however, face challenges in designing sound effectiveness and translation research with relevance for “real-world” settings. Methods: Research experts and federal and foundation funders (n!"120) prepared for and participated in a symposium, held May 4–5, 2004, to weigh the strengths, limitations, and trade-offs between alternate designs for studying the effectiveness and translation of complex, multilevel health interventions. Results: Symposium attendees acknowledged that research phases (hypothesis generating, efficacy, effectiveness, translation) are iterative and cyclical, not linear, since research in advanced phases may reveal unanswered questions in earlier phases. Research questions thus always need to drive the choice of study design. When randomization and experimental control are feasible, participants noted that the randomized controlled trial with individual random assignment remains the gold standard for safeguarding internal validity. Attendees highlighted trade-offs of randomized controlled trial variants, quasi-experimental designs, and natural experiments for use when randomization or experimental control or both are impossible or inadequately address external validity. Participants discussed enhancements to all designs to increase confidence in causal inference while accommodating greater external validity. Since no single study can establish causality, participants encouraged replication of studies and triangulation using different study designs. Participants also recommended participatory research approaches for building population relevance, acceptability, and usefulness. Conclusions: Consideration of the study design choices, trade-offs, and enhancements discussed here can guide the design, funding, completion, and publication of appropriate policy- and practice-oriented effectiveness and translational research for complex, multilevel health interventions.

OBJECTIVE: To establish whether the timing of delivery between 37 and 42 weeks gestation influences neonatal respiratory outcome and thus provide information which can be used to aid planning of elective delivery at term.
DESIGN: All cases of respiratory distress syndrome or transient tachypnoea at term requiring admission to the neonatal intensive care unit were recorded prospectively for nine years.
SETTING: Rosie Maternity Hospital, Cambridge.
SUBJECTS: During this time 33,289 deliveries occurred at or after 37 weeks of gestation.
MEASURES: This information enabled calculation of the relative risk of respiratory morbidity for respiratory distress syndrome or transient tachypnoea in relation to mode of delivery and onset of parturition for each week of gestation at term.
RESULTS: The incidence of respiratory distress syndrome at term was 2.2/ 1000 deliveries (95 % CI; 1.7-2.7). The incidence of transient tachypnoea was 5.7/1000 deliveries (95 % CI; 4.9-65). The incidence of respiratory morbidity was significantly higher for the group delivered by caesarean section before the onset of labour (35.5/ 1000) compared with caesarean section during labour (12.2/1000) (odds ratio, 2.9; 95% CI 1.9-4.4; P <0.001), and compared with vaginal delivery (5.3/1000) (odds ratio, 6.8; 95 % CI 52-8.9; P < 0.001). The relative risk of neonatal respiratory morbidity for delivery by caesarean section before the onset of labour during the week 37+0 to 37+6 compared with the week 38+0 to 38+6 was 1.74 (95 % CI 1.1 -2.8 ; P < 0.02) and during the week 38+O to 38+6 compared with the week 39+0 to 39+6 was 2.4 (95% CI 1.2-4.8; P < 0.02).
CONCLUSIONS: A significant reduction in neonatal respiratory morbidity would be obtained if elective caesarean section was performed in the week 39+0 to 39+6 of pregnancy.

This article describes common quantitative design techniques that can be used to collect and analyze quality data. An understanding of the differences between these design techniques can help healthcare quality professionals make the most efficient use of their time, energies, and resources. To evaluate the advantages and disadvantages of these various study designs, it is necessary to assess factors that threaten the degree with which quality professionals may infer a cause-and-effect relationship from the data collected. Processes, the conduits of organizational function, often can be assessed by methods that do not take into account confounding and compromising circumstances that affect the outcomes of their analyses. An assumption that the implementation of process improvements may cause real change is incomplete without a consideration of other factors that might also have caused the same result. It is only through the identification, assessment, and exclusion of these alternative factors that administrators and healthcare quality professionals can assess the degree to which true process improvement or compliance has occurred. This article describes the advantages and disadvantages of common quantitative design techniques and reviews the corresponding threats to the interpretability of data obtained from their use. PMID: 11378972 [PubMed - indexed for MEDLINE]

OBJECTIVE: The American College of Obstetricians and Gynecologists has recommended that elective deliveries not be performed before 39 weeks of gestation, to minimize prematurity-related neonatal complications. Because a worrisome number of elective deliveries were occurring before 39 weeks of gestation in our system, we developed and implemented a program to decrease the number of these early term elective deliveries. Secondary objectives were to monitor relevant clinical outcomes.
METHODS: The electronic medical records of an integrated health care system involving nine labor and delivery units in Utah were queried to establish the incidence of patients admitted for elective induction of labor or planned elective cesarean delivery. These facilities have open staff models with obstetricians, family practitioners, and certified nurse midwives. Guidelines were developed and implemented to discourage early term elective deliveries. The prevalence of early term elective deliveries was tracked and reported back regularly to the obstetric leadership and obstetric departments at each facility.
RESULTS: The baseline prevalence of early term elective deliveries was 28% of all elective deliveries before the initiation of the program. Within 6 months of initiating the program, the incidence of near-term elective deliveries decreased to less than 10% and after 6 years continues to be less than 3%. A reduced length of stay in labor and delivery occurred with the introduction of the program, and there were no adverse effects on secondary clinical outcomes.
CONCLUSION: With institutional commitment, it is possible to substantially reduce and sustain a decline in the incidence of elective deliveries before 39 weeks of gestation.

Background: Obstetric drills are being used increasingly to test, improve, and maintain knowledge and skills related to obstetric emergencies as a means to improve proficiency and efficiency of practitioners. The purpose of this study was to assess the feasibility and usefulness of conducting drills to evaluate the response to obstetric emergencies using a holistic approach that tested the hospital system. Methods: A prospective trial was conducted at three hospitals (two tertiary referral centers and one small community hospital) in Beirut, Lebanon. Two different emergency obstetric drills at two points in time were conducted between April and May 2006 either in the emergency room or on the labor floor. The drills included medical and paramedical staff, a female actor (simulating a pregnant woman), a research assistant (acting as her companion), and a physician trained in obstetrics (the drill leader). Responses were recorded and critically analyzed. Results: Although overall quality of care was within standards of care, problems were identified related to hospital policies, supplies and equipment, communication, and clinical management. Some technical problems related to administration of the drills were identified. Most drill participants appreciated the exercise and found it beneficial. Conclusions: Obstetric drills provide a useful tool to identify and address deficiencies in the hospital system. This finding could have implications on improving quality of care provided to obstetric patients.

OBJECTIVE: The objective of this paper was to present a comprehensive approach to help health care organizations reliably deliver effective interventions.
CONTEXT: Reliability in healthcare translates into using valid rate-based measures. Yet high reliability organizations have proven that the context in which care is delivered, called organizational culture, also has important influences on patient safety.
MODEL FOR IMPROVEMENT: Our model to improve reliability, which also includes interventions to improve culture, focuses on valid rate-based measures. This model includes (1) identifying evidence-based interventions that improve the outcome, (2) selecting interventions with the most impact on outcomes and converting to behaviors, (3) developing measures to evaluate reliability, (4) measuring baseline performance, and (5) ensuring patients receive the evidence-based interventions. The comprehensive unit-based safety program (CUSP) is used to improve culture and guide organizations in learning from mistakes that are important, but cannot be measured as rates.
CONCLUSIONS: We present how this model was used in over 100 intensive care units in Michigan to improve culture and eliminate catheter-related blood stream infections--both were accomplished. Our model differs from existing models in that it incorporates efforts to improve a vital component for system redesign--culture, it targets 3 important groups--senior leaders, team leaders, and front line staff, and facilitates change management-engage, educate, execute, and evaluate for planned interventions.

OBJECTIVE: Our goal was to lower unplanned primary cesarean deliveries by reducing elective inductions. STUDY DESIGN: To implement and sustain an induction management program, a committee of care providers reviewed induction rates. “Elective” and other categories were defined. An induction consent form was drafted. Consent compliance, induction rates, hours in labor and delivery and mode of delivery were evaluated. Outcomes were compared with historical data from 2 years earlier. RESULTS: A total of 10,166 nulliparas and 9869 multiparas attempted vaginal deliveries. Elective inductions decreased significantly, from 4.3% to 0.8% in nulliparas and from 13% to 9.5% in multiparas. A longer time to delivery was seen for both nulliparas (5.2 hours) and multiparas (4 hours) with elective inductions. Unplanned primary cesarean delivery rates are significantly lower in spontaneously laboring women, compared with those induced. CONCLUSION: A program aimed at reducing elective inductions was successfully implemented and sustained.

This study reviewed maternal morbidity following trial of labor (TOL) after cesarean section, compared with elective repeat cesarean delivery (ERCS). Articles were pooled to compare women planning vaginal birth after cesarean (VBAC) with those undergoing ERCS with regard to maternal morbidity (MM), uterine rupture/dehiscence (UR/D), blood transfusion (BT), and hysterectomy. The former group was subdivided into successful VBAC (S-VBAC) and failed TOL (F-TOL). VBAC was successful in 17,905 of 24,349 patients (73%). MM, BT, and hysterectomy were similar in women planning VBAC or ERCS, whereas UR/D was different (1.3%; 0,4%). MM, UR/D, BT and hysterectomy were more common after F-TOL (17%, 4.4%, 3%; 0.5%) than after S-VBAC (3.1%, 0.2%, 1.1%; 0.1%) or ERCS (4.3%, 0.4%, 1%; 0.3%). Outcomes were more favorable in S-VBAC than ERCS. These findings show that a higher risk of UR/D in women planning VBAC than ERCS is counterbalanced by reduction of MM, UR/D. and hysterectomy when VBAC is successful.

Failure to rescue is an indicator that has been used to measure quality of care for surgical patients by evaluating the number of patients who die after developing postoperative complications. There are 2 key components of failure to rescue: (a) careful surveillance and timely identification of complications and (b) taking action by quickly initiating appropriate interventions and activating a team response. This concept has not been explored as a potential method to evaluate quality of intrapartum care. In obstetrics, complications leading to death are relatively rare because mothers and infants are generally healthy. Thus, there are not large numbers of maternal or infant deaths in individual hospitals or healthcare systems that allow the types of statistical analyses that have been previously used to measure failure to rescue rates. With modifications in the measurement process for failure to rescue in this population, there are direct implications for perinatal patient safety and lessons to be learned. A new use of the failure to rescue concept in a population not previously considered is proposed.

Implementation Science (IS) is a new branch of health services research (HSR) that strives to increase the efficiency and effectiveness of health care quality improvement (QI) efforts. Despite the fact that IS takes a systems approach, building contextual factors into its research designs, the complex systems context of IS itselfdand the impact this context has on IS practicedhas never been scrutinized. Using individual interviews and participant observation, the research described here characterizes key contextual factors affecting how implementation scientists in one large health care organization approach and conduct their research. Some of the organizational and professional system forces structuring their attitudes and actions were grant-related timelines, administrative burdens, and team turnover. The need for publications also figured highly. While such pressures (and related responses to them) may be rife in most grant-funded health care research settings, IS’s particularly marginal position drove these implementation scientists to strategically highlight particular aspects of their work depending on which audience or part of the system they required favor from. Their narratives illuminate the contradictions and contests entailed within and engendered by organizational and professional structures, and the strategies used to negotiate these. They also reveal a great deal about the struggles underwriting disciplinary identity claims in a complex systems context.

Background. To elucidate the patient safety practices of obstetrician-gynecologists (OB/GYNs),the perceived barriers to patient safety improvements in obstetrics and gynecology, and OB/GYN’s beliefs about mandated reporting. Methods. A sample of 600 OB/GYNs was sent a survey from the American College of Obstetricians and Gynecologists about their beliefs and practice regarding patient safety. Results. The response rate was 53.2%. More than 92% of respondents said that patient safety is important in women’s health care. The most important barriers to improving patient safety were cost of new technologies and concern about liability. Half agreed that mandatory reporting would improve patient safety. Physicians who practice in states with mandated error reporting were no more or less likely to think that these mandates improve patient safety than physicians who do not work in states with mandates. Physicians who practice in states with ‘‘I’m Sorry’’ laws more strongly disagreed that mandates improve patient safety than physicians who do not work in states with ‘‘I’m Sorry’’ laws. Discussion and Conclusions. It may be effective to aim at making patient safety activities more affordable to increase implementation. In addition, the effects of reporting and disclosure laws on physicians’ concerns with liability should be examined more closely.

Background: Gaps between evidence and practice in the care of patients with chronic heart failure (CHF) in the United States suggest major opportunities for improvement. However, the organizational factors and implementation approaches that influence adherence to national guidelines are poorly understood. Objectives: The objectives of this study were to explore the degree to which providers in the Veterans Health Administration system adhere to CHF clinical practice guidelines, and to identify facilitylevel factors influencing adherence. Design: In a national cross-sectional study, facility quality managers were surveyed regarding quality improvement efforts, guideline implementation, and context. These data were linked to organizational structure data and provider adherence data from chart reviews. The unit of analysis was the facility. The data were adjusted for the average number of comorbidities per CHF patient. Multivariate logistic regression models were constructed to model factors affecting adherence to CHF guidelines. Sample: The sample consisted of 143 Veterans Administration Medical Centers with ambulatory care clinics. Results: The quality manager survey included data from 91% of facilities. Facility-level estimates of provider adherence measures were, on average, 85% or more for most measures. In multivariate analyses, facilities with higher levels of adherence were more likely to have: (1) providers who had been given a brief guideline summary, (2) providers receptive to the guidelines, (3) guideline-specific task forces to support implementation, and 4) a well-planned implementation process. Conclusions: Healthcare organizations should adapt implementation to meet local conditions, including creating guideline-specific task forces, developing a well-planned implementation process, fostering provider buy-in, and providing guideline summaries to providers.

Aims. 1. Ascertain antenatal and intrapartum risk factors for term neonates ventilated primarily for ‘perinatal asphyxia’. 2. Describe the neonatal morbidity and mortality. Methods. Population-based case control cohort study. Setting. Sydney and four large rural/urban health areas in New South Wales. Subjects. Singleton term infants, no major congenital anomaly: subset of 83 infants ventilated primarily for ‘asphyxia’ from 182 cases admitted to a tertiary neonatal intensive care unit (NICU) for mechanical ventilation, 550 randomly selected controls. Outcome. Risk factors for case status by maternal, antenatal, labor, delivery, and combined epochs, adjusted odds ratios (OR), 95 per cent confidence intervals (CI), p􏰁0.05. Results. Predictors of case status by multivariate epochs: Primigravida (1.8 [1.1, 2.8]), thyroid disease (7.8 [1.1, 57.0]), any antenatal complication (5.1 [3.0, 8.6]), growth restriction (4.2 [1.7, 10.4]), male gender (2.1 [1.3, 3.5]), gestational age 􏰂40 weeks (1.9 (1.1, 3.3)), prolonged rupture of membranes (9.7 [1.3, 72.5]), complicated labor (6.6 [3.7, 11.9]), induced labor (2.2 [1.3, 3.9]), prostaglandins 2.46 [1.23, 4.91]), maternal pyrexia (10.8 [2.8, 42.7]), placental hemorrhage in labor (OR 4.24 [1.45, 12.42]), forceps delivery (4.1 [1.9, 8.5]), emergency cesarean section (4.7 [2.6, 8.7]). Twenty case infants (24%) and no control infants died. Conclusions. This study has shown maternal and antepartum risk factors for severe neonatal morbidity in term infants. More centers need to become interested in the term baby, so that a larger multicenter study can further elucidate the heterogeneous causal pathways to term neonatal morbidity.

AIMS: 1. Ascertain antenatal and intrapartum risk factors for term neonates ventilated primarily for respiratory problems. 2. Describe the neonatal morbidity and mortality. Methods. Population-based case control cohort study. SETTING: Sydney and four large rural/urban Health Areas in New South Wales, 1996. SUBJECTS: Singleton term infants, no major congenital anomaly: subset of 99 infants ventilated primarily for respiratory problems from 182 cases admitted to a tertiary neonatal intensive care unit (NICU) for mechanical ventilation, and 550 randomly selected controls. OUTCOME: Risk factors for case status by maternal, antenatal, labor, delivery, and combined epochs, adjusted Odds Ratios (OR), 95 per cent Confidence Intervals (CI), p<0.05. RESULTS: Predictors of case status by multivariate epochs: mother’s age >35 years (1.9 (1.1, 3.2) p<0.03), primigravida (1.8 (1.1, 2.8) p<0.01), any antenatal complication (3.8 (2.4, 5.9) p<0.0001), birth weigh<3rd percentile (3.7 (1.5, 9.1) p<0.006), gestational diabetes (2.9 (1.3, 6.9) p<0.01), maternal pyrexia (6.5 (1.6, 27.2) p<0.01), birth weight >90th percentile (1.8 (1.01, 3.2) p<0.047), gestation 37–38 weeks (2.3 (1.5, 3.6) p<0.0004), forceps (4.4 (2.1, 9.1) p<0.0001), elective cesarean section (3.7 (2.0, 6.5) p<0.0001), emergency cesarean section (4.5 (2.4, 8.4) p<0.0001). Case mortality rate was 5 per cent. CONCLUSIONS: The pathways to neonatal respiratory morbidity in term infants are multifactorial. Several areas which warrant more in-depth study are: elective cesarean section at 37–38 weeks gestation, fetal growth restriction, macrosomia and the pattern of in-utero growth, maternal weight gain during pregnancy, gestational diabetes, pyrexia in labor and the role of chorioamnionitis.

Background: Because of increased rates of respiratory complications, elective cesarean delivery is discouraged before 39 weeks of gestation unless there is evidence of fetal lung maturity. We assessed associations between elective cesarean delivery at term (37 weeks of gestation or longer) but before 39 weeks of gestation and neonatal outcomes. Methods: We studied a cohort of consecutive patients undergoing repeat cesarean sections performed at 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network from 1999 through 2002. Women with viable singleton pregnancies delivered electively (i.e., before the onset of labor and without any recognized indications for delivery before 39 weeks of gestation) were included. The primary outcome was the composite of neonatal death and any of several adverse events, including respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (ICU). Results:Of 24,077 repeat cesarean deliveries at term, 13,258 were performed electively; of these, 35.8% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.5% at 38 weeks) and 49.1% at 39 weeks of gestation. One neonatal death occurred. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend <0.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks. Conclusions: Elective repeat cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes.

Evidence-based medicine is an important tool for improving the quality of maternity care. However, getting providers to change their practices may not be an easy or rapid process, and other factors, in addition to knowledge of the literature, may be important. This study documents the current state of obstetric practices at three maternity hospitals in Istanbul, Turkey, and identifies attitudes, social pressures, and perceptions that, according to the theory of planned behavior, may pose challenges for adoption of evidence-based practices. Data were collected through interviews with administrators, examination of hospital statistics, provider and client interviews, and structured observations of maternity care. Practices that did not follow current guidelines included routine episiotomy, not allowing companionship during labor, use of procedures to speed up labor without indications, routine enema, restriction of mobility, restriction of oral fluids, supine position for delivery, and non-use of active management of the third stage of labor. The findings indicate that providers had negative attitudes about some recommended practices, while they had positive attitudes towards some ineffective and/or harmful practices. We identified social pressure to comply with practices recommended by supervisors and peers, as well as the belief that limited resources affect maternity care providers, opportunities to perform evidence-based procedures. An underlying problem was the failure to involve women in decision-making regarding their own maternity care. In addition to informing providers about the evidence, it seems necessary to develop standard protocols, improve physical conditions, and implement behavior interventions that take into account provider attitudes, social pressures, and beliefs.

Background: Collaborative approaches in quality improvement have been promoted since the introduction of the Breakthrough method. The effectiveness of this method is inconclusive and further independent evaluation of the method has been called for. For any evaluation to succeed, data collection on interventions performed within the collaborative and outcomes of those interventions is crucial. Getting enough data from Quality Improvement Collaboratives (QICs) for evaluation purposes, however, has proved to be difficult. This paper provides a retrospective analysis on the process of data management in a Dutch Quality Improvement Collaborative. From this analysis general failure and success factors are identified. Discussion: This paper discusses complications and dilemma's observed in the set-up of data management for QICs. An overview is presented of signals that were picked up by the data management team. These signals were used to improve the strategies for data management during the program and have, as far as possible, been translated into practical solutions that have been successfully implemented. The recommendations coming from this study are: From our experience it is clear that quality improvement programs deviate from experimental research in many ways. It is not only impossible, but also undesirable to control processes and standardize data streams. QIC's need to be clear of data protocols that do not allow for change. It is therefore minimally important that when quantitative results are gathered, these results are accompanied by qualitative results that can be used to correctly interpret them. Monitoring and data acquisition interfere with routine. This makes a database collecting data in a QIC an intervention in itself. It is very important to be aware of this in reporting the results. Using existing databases when possible can overcome some of these problems but is often not possible given the change objective of QICs. Introducing a standardized spreadsheet to the teams is a very practical and helpful tool in collecting standardized data within a QIC. It is vital that the spreadsheets are handed out before baseline measurements start.

Most health care professionals who are involved in efforts to improve patient safety are aware of James Reason’s “Swiss cheese” model of how accidents occur. Some elements and pressures of current obstetric practice may weaken defenses and safeguards against perinatal injury. Several components of obstetric care in labor and delivery units can be used as targets for tightening the “holes” in the Swiss cheese model. These include improving communications, preparing for rare critical events through simulation training, developing protocols for administration of important medications used in labor and delivery (oxytocin, misoprostol, and magnesium sulfate), increasing the in-house presence of obstetricians, developing an effective departmental infrastructure that includes effective peer review, providing risk management education about high-risk clinical areas that have the potential to result in catastrophic injury, and staffing the unit for all contingencies during all hours, day and night. Acceptance by the obstetric medical staff is critical to the implementation of these patient safety elements. (Obstet Gynecol 2007;110:1146–50)

What is already known about the topic?  Knowledge translation research in nursing is predominated of descriptive studies.  A valid knowledge base for issuing recommendations on implementation strategies is lacking. What this paper adds?  A description of intervention strategies used in recent implementation research in nursing.  An analysis and discussion of issues involved in the evaluation of complex interventions for implementing evidence-based practice.

The paper explores the attitudes of medical physicians towards adverse incident reporting in health care, with particular focus on the inhibiting factors or barriers to participation. It is recognised that there are major barriers to medical reporting, such as the ‘culture of blame’. There are, however, few detailed qualitative accounts of medical culture as it relates to incident reporting. Drawing on a 2-year qualitative case study in the UK, this paper presents data gathered from 28 semi-structured interviews with specialist physicians. The findings suggest that blame certainly inhibits medical reporting, but other cultural issues were also significant. It was commonly accepted by doctors that errors are an ‘inevitable’ and potentially unmanageable feature of medical work and incident reporting was therefore ‘pointless’. It was also found that reporting was discouraged by an anti-bureaucratic sentiment and rejection of excessive administrative duties. Doctors were also apprehensive about the increased potential for managers and non-physicians to engage in the regulation of medical quality through the use of incident data. The paper argues that the promotion of incident reporting must engage with more than the ubiquitous ‘culture of blame’ and instead address the ‘culture of medicine’, especially as it relates to the collegial and professional control of quality.

‘Systems thinking’ is an important feature of the emerging ‘patient safety’ agenda. As a key component of a ‘safety culture’, it encourages clinicians to look past individual error to recognize the latent factors that threaten safety. This article investigates whether current medical thinking is commensurate with the idea of ‘systems thinking’ together with its implications for policy. The fi ndings are based on qualitative semi-structured interviews with specialist physicians working within one NHS District General Hospital in the English Midlands. It is shown that, rather then favouring an individualized or ‘person-centred’ perspective, doctors readily identify ‘the system’ as a threat to patient safety. This is not necessarily a refl ection of the prevailing safety discourse or knowledge of policy, but refl ects a tacit understanding of how services are (dis)organized. This line of thinking serves to mitigate individual wrongdoing and protect professional credibility by encouraging doctors to accept and accommodate the shortcomings of the system, rather than participate in new forms of organizational learning.

Objective. To determine the relationship between variations in hospital incident reporting and the corresponding attitudes and participation of medical professionals. Methods. An in-depth qualitative case study using semi-structured interviews with hospital managers and clinicians. Twelve participants were theoretically sampled based on their involvement with clinical risk management and patient safety. Twentyfive medical physicians and four risk leads were selected from the specialist hospital departments of Obstetrics, Anaesthesia, General Surgery, Acute Medicine, and Rehabilitation. The data were analysed to develop a descriptive account of the intrahospital variations in reporting and the associated attitudes of physicians. Setting. The research was conducted in a single acute National Health Service Hospital Trust in the English Midlands. Results. The qualitative data revealed significant variations in the intra-hospital organization of incident reporting between medical specialities that corresponded with the attitudes and participation of medical staff. Specifically, it was found that medical doctors were more inclined to report incidents where the process of reporting was localized and integrated within medical rather than managerial systems of quality improvement. Underlying these variations, it is suggested that medical reporting is more likely when physicians have greater control or ownership of incident reporting, as this fosters confidence in the purpose of reporting, in particular its capacity to make meaningful service improvements whilst maintaining a sense of collegiality and professionalism.

The current professional liability crisis is the third in the last 30 years. Similarities of the 3 crises are the rising cost of professional liability insurance and a diminishing number of sources available to purchase coverage. Proposed tort reform with caps on noneconomic damages and attorney contingency fees is a back end approach and will do little to solve this crisis or prevent future ones. The current situation can only be solved by placing an increased emphasis on improving patient safety and elimination of all preventable medical errors. A national electronic medical record must be developed and rapid response teams need to be available in most hospitals. The protective devices of privileged communication and peer review are counterproductive and must be eliminated. Full and prompt disclosure of any medical error or injury needs to be made. Physicians must be taught proper communication skills and the importance of teamwork. Providers with frequent patient, nursing or medical staff complaints must be critically reviewed. The present system of risk management needs to move from a reactive position to a role of being proactive for both patient and physician. Claims management should offer the patient early compensation when appropriate and pursue a vigorous defense when medical care is adequate. Experts should be identified who will render fair, unbiased reviews of medical care with all of their findings being disclosed. Similar experts need to devise clear, concise, evidenced based standards of care for common medical conditions.

The relationship between human resource management practices and organizational performance (including quality of care in health-care organizations) is an important topic in the organizational sciences but little research has been conducted examining this relationship in hospital settings. Human resource (HR) directors from sixtyone acute hospitals in England (Hospital Trusts) completed questionnaires or interviews exploring HR practices and procedures. The interviews probed for information about the extensiveness and sophistication of appraisal for employees, the extent and sophistication of training for employees and the percentage of staff working in teams. Data on patient mortality were also gathered. The Ž ndings revealed strong associations between HR practices and patient mortality generally. The extent and sophistication of appraisal in the hospitals was particularly strongly related, but there were links too with the sophistication of training for staff, and also with the percentages of staff working in teams.

OBJECTIVES: To describe variation across Europe in PERISTAT indicators of health care in the perinatal period, and to assess the comparability of these indicators.
STUDY DESIGN: The PERISTAT feasibility study provides the source for this descriptive study, covering 15 European countries. Comparative analysis includes descriptions of births following management of sub-fertility, timing of first antenatal visit, onset of labour, mode of delivery, place of birth, preterm births in units without NICU, and breast-feeding uptake.
RESULTS: There is broad variation in the availability to provide data on perinatal indicators, and in perinatal health care across the European Union.
CONCLUSIONS: This paper describes the challenge of identifying indicators that are meaningful and robust for the full distribution of health care systems represented in the European Union. Further work is needed to ensure that the implementation of each indicator is comparable across member states.

Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. Every day, clinical decisions at the bedside, rules of operation at hospitals and clinics, and health spending by governments and insurers are being influenced by guidelines. As defined by the Institute of Medicine, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”1 They may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, how long patients should stay in hospital, or other details of clinical practice. The broad interest in clinical guidelines that is stretching across Europe, North America, Australia, New Zealand, and Africa (box) has its origin in issues that most healthcare systems face: rising healthcare costs, fueled by increased demand for care, more expensive technologies, and an ageing population; variations in service delivery among providers, hospitals, and geographical regions and the presumption that at least some of this variation stems from inappropriate care, either overuse or underuse of services; and the intrinsic desire of healthcare professionals to offer, and of patients to receive, the best care possible. Clinicians, policy makers, and payers see guidelines as a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports. As guidelines diffuse into medicine, there are important lessons to learn from the firsthand experience of those who develop, evaluate, and use them.3 This article, the first of a four part series to reflect on these lessons, examines the potential benefits, limitations, and harms of clinical guidelines. Future articles will review lessons learned about their development,4 legal and emotional ramifications,5 and finally their implementation

BACKGROUND: The PERISTAT project aimed to develop an indicator set for monitoring and describing perinatal health in Europe. The challenge was to define indicators that cover common concerns and have the same meaning within the different European health care systems.
METHODS: PERISTAT included i) a review of existing recommendations on perinatal health indicators, ii) a DELPHI consensus process with a scientific advisory committee composed of a clinician and an epidemiologist or statistician from each European member state as well as with a panel of midwives, and iii) a study of the availability of national statistics to construct recommended indicators. This article describes the first two components.
RESULTS: The review identified 10 international and 13 national recommended indicator sets. It also included indicators routinely compiled by WHO, EUROSTAT and OECD. Because of the methodological limits to using existing indicators for European comparisons, a high priority was placed on improving indicators already collected. Using the DELPHI method based on the results of the review, the scientific committee achieved a consensus on ten core and 23 recommended indicators, including 12 requiring further development.
CONCLUSIONS: The PERISTAT project was successful in identifying a set of indicators, which drew on and consolidated previous work. Consensus was not achieved on precise indicators in areas where uncertainty about appropriate indicators was high, although areas were targeted for future development. Finally, the feasibility study, which is in progress, is an essential part of the project, since it will enable member states to evaluate their capacity to produce these indicators.

The PERISTAT project was charged with developing an indicator set for monitoring and describing perinatal health in Europe as part of the European Commission's Health Monitoring Programme, run by the Directorate General for Health and Consumer Protection (DG-SANCO), which is working towards the establishment of a comprehensive health monitoring system at the community level. To develop its recommendations, the PERISTAT project carried out an extensive review of existing perinatal health indicators and then implemented a DELPHI consensus process with its scientific advisory committee, a panel composed of clinicians, epidemiologists and statisticians, as well as with a panel of midwives. Consensus was achieved on 10 core and 23 recommended indicators using methods that drew on and consolidated previous work in this field. Twelve of these indicators were targeted for further development and the other 21 for immediate implementation. A feasibility study, reported in the rest of this issue, was put into place to assess these recommendations.

About WhyNotTheBest.org WhyNotTheBest.org was created and is maintained by The Commonwealth Fund, a private foundation working toward a high performance health system. It is a free resource for health care professionals interested in tracking performance on various measures of health care quality. It enables organizations to compare their performance against that of peer organizations, against a range of benchmarks, and over time. Case studies and improvement tools spotlight successful improvement strategies of the nation’s top performers. Currently, the site includes measures of hospital quality that are publicly reported on the Centers for Medicare and Medicaid Services Web site, Hospital Compare. Specifically, it includes 24 Hospital Quality Alliance measures that report how often hospitals deliver recommended care processes for the following four conditions: heart attack, heart failure, pneumonia, and surgical care improvement. In addition, it includes 10 measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which reports hospital patients’ satisfaction with their care. We will update these data sets four times a year. Data are included for nearly all U.S. hospitals, some 4,440. Click here to view the specific measures. We will continue to add new measure sets and develop additional functionality over time. If you would like to stay informed of new data or features on WhyNotTheBest.org, please sign up for e-mail alerts. If you would like to provide feedback on the site or make a suggestion for improvement, please contact wntb@cmwf.org. If you are having technical problems with the site, please contact wntb-support@ipro.us. For information on how we use these data to create composites measures and rank hospitals according to their performance levels, please visit the Methodology Section.

DESCRIPTION: Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section.
RATIONALE: The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section (CS) rates. Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Gould et al., 2004). There are no data that higher rates improve any outcomes, yet the CS rates continue to rise. This measure seeks to focus attention on the most variable portion of the CS epidemic, the term labor CS in nulliparous women. This population segment accounts for the large majority of the variable portion of the CS rate, and is the area most affected by subjectivity. As compared to other CS measures, what is different about NTSV CS rate (Low-risk Primary CS in first births) is that there are clear cut quality improvement activities that can be done to address the differences. Main et al. (2006) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Alfirevic et al. (2004) also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003). The dramatic variation in NTSV rates seen in all populations studied is striking according to Menacker (2006). Hospitals within a state (Coonrod et al., 2008; California Office of Statewide Hospital Planning and Development [OSHPD], 2007) and physicians within a hospital (Main, 1999) have rates with a 3-5 fold variation.
TYPE: Outcome.
IMPROVEMENT: Decrease in the rate.
NUMERATOR: Patients with cesarean sections Included Populations: ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for cesarean section as defined in Appendix A, Table 11.06 Excluded Populations: None Data Elements: ICD-9-CM Other Procedure Codes ICD-9-CM Principal Procedure Code
DENOMINATOR: Nulliparous patients delivered of a live term singleton newborn in vertex presentation Included Populations: Nulliparous patients with ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for outcome of delivery as defined in Appendix A, Table 11.08 and with a delivery of a newborn with 37 weeks or more of gestation completed Excluded Populations: * ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes, for contraindications to vaginal delivery as defined in Appendix A, Table 11.09 Less than 8 years of age Greater than or equal to 65 years of age Length of Stay >120 days Enrolled in clinical trials

Arguably the greatest achievement of academic health services research of the last half-century has created its greatest unmet challenge. The achievement is to have documented beyond doubt the widespread defects in health care, even in wealthy systems. The challenge is to discover what we need to know that we do not now know in order to create much more effective systems of care. Health services research has not yet been sufficiently helpful in meeting the challenge of improving care in part because it has over-constrained both its methods and its favorite topics. The cost of insisting on formal, classical, summative, evaluative experimental designs in an uncertain, poorly understood, nonlinear, system is, unfortunately, to maintain the status quo. When the status quo is harmful, as health care is today, harm is not a theoretical problem. It is real, and it is indecent. Health services research should become more effectively part of the solution. To do that will require that we enrich our portfolio of methods and broaden our agenda of inquiry. The scientific methods that we need to enhance and dignify in academic settings will combine formal classical methods with some pragmatic, immediate, and in many ways more informative forms of learning and investigation.

Fifteen months after releasing its report on patient safety (To Err Is Human), the Institute of Medicine released Crossing the Quality Chasm. Although less sensational than the patient safety report, the Quality Chasm report is more comprehensive and, in the long run, more important. It calls for improvements in six dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity; and it asserts that those improvements cannot be achieved within the constraints of the existing system of care. It provides a rationale and a framework for the redesign of the US health care system at four levels: patients' experiences; the "Microsystems" that actually give care; the organizations that house and support Microsystems; and the environment of laws, rules, payment, accreditation, and professional training that shape organizational action.

editorial

Studies of quality improvement are often poorly reported. The Standards for Quality Improvement Reporting Excellence (SQUIRE) Group describes how its guidelines could improve standards

As the nation’s hospitals face increasing demands to participate in a wide range of quality improvement activities, the role and influence of nurses in these efforts is also increasing, according to a new study by the Center for Studying Health System Change (HSC). Hospital organizational cultures set the stage for quality improvement and nurses’ roles in those activities. Hospitals with supportive leadership, a philosophy of quality as everyone’s responsibility, individual accountability, physician and nurse champions, and effective feedback reportedly offer greater promise for successful staff engagement in improvement activities. Yet hospitals confront challenges with regard to nursing involvement, including: scarcity of nursing resources; difficulty engaging nurses at all levels—from bedside to management; growing demands to participate in more, often duplicative, quality improvement activities; the burdensome nature of data collection and reporting; and shortcomings of traditional nursing education in preparing nurses for their evolving role in today’s contemporary hospital setting. Because nurses are the key caregivers in hospitals, they can significantly influence the quality of care provided and, ultimately, treatment and patient outcomes. Consequently, hospitals’ pursuit of high-quality patient care is dependent, at least in part, on their ability to engage and use nursing resources effectively, which will likely become more challenging as these resources become increasingly limited.

The Seventh Report of the United Kingdom Confidential Enquires into Maternal Deaths (2003-2005). Slide set provided by Dr Gwyneth Lewis, CEMACH Clinical Director, Maternal Death Enquiry.

In the last decade, growing evidence that the quality of U.S. health care is uneven at best has prompted greater attention to quality improvement, especially in the nation’s hospitals. While physicians are integral to hospital quality improvement efforts, focusing physicians on these activities is challenging because of competing time and reimbursement pressures. To overcome these challenges, hospitals need to employ a variety of strategies, according to a Center for Studying Health System Change (HSC) study of four communities—Detroit, Memphis, Minneapolis-St. Paul and Seattle. Hospital strategies include employing physicians; using credible data to identify areas that need improvement; providing visible support through hospital leadership; identifying and nurturing physician champions to help engage physician peers; and communicating the importance of physicians’ contributions. While hospitals are making gains in patient care quality, considerably more progress likely could be made through greater alignment of hospitals and physicians working together on quality improvement.

An overview of the role of the California Maternal Quality Care Collaborative (CMQCC) to reduce the rising rates of maternal mortality and the associated increase in maternal morbidity in the state of California. The innovative connection of a quality improvement collaborative with the California Pregnancy-Related and Pregnancy-Associated Mortality Review committee facilitates the more rapid diffusion of findings into action.

A reasonable trigger tool for nursing charting on L&D. From: Appendix to Saving Mother's Lives (2007); also published in: International Journal of Obstetric Anesthesia (2006) 15, S1-S43 Abstracts of free papers presented at the annual meeting of the Obstetric Anaesthetists? Association, Glasgow 11-12 May, 2006. “Early-warning scoring in obstetrics”. P Harrison, C Hawe, F McIlveney. Department of Anaesthesia, Stirling Royal Infirmary, Stirling, UK.